Credit Card Refund Request

To be completed by Bursar

ProcessedNo Credit DueBank Mobile Refund
Credit Card Refund Request
Please fill out the Web Payment Refund Request Form and return it to the Bursar's Office via email or in person.

All refunds for fees paid by credit cards and by Web ACH must be credited back to the account used to make payment.
Student Name*
LoLA Number*
Address*

Address

Street Address Line 2

City, State ZipState / Province

Postal / Zip Code
Phone Number*
E-mail Address*
example@example.com
Card Type*

VisaMasterCardDiscoverAmerican Express
Amount*
Full or Partial Refund*

Full Credit Card PaymentPartial Credit Card Payment
Name on Card*
Billing Zip Code*
I hereby authorize Delgado Community College to credit my above-mentioned credit card for the refunded amount requested. I understand that this information will be used for the purpose of verification and refund. By submitting this form, I acknowledge this information to be valid.
Signature*

Clear
Date*

MonthDayYear
Date
Copy of Credit Card Holder's State Issued Photo ID*

Cancelof
Please verify that you are human*
Type a question
Should be Empty: